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Versionl.7 Commercial Building Permit May 15, 2000
SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes O No Q
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
SteveBalicki / Clarke School for the deaf
as Owner of the subject property
hereby authorize John Scott to
act on my behalf, in all matters re •v to work authorized by this building permit application.
V R64, 07/20/2009
Signature of Owner Date
Steve Balicki /Clarke School for the deaf
l
, as Owner /Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of periu .
Steve Balicki "!
Print Name � •� A� �
}7J �$ 07/20/2009
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : . John Scott CS 78899
License Number
. _.
11 Hunt Rd. Hawley, Ma. 01339 A 03/18/2011
Address Expiration Date
(413) 339 -5508
Signature Telephone
SECTION 13 - WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes 0 No 0
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name (Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
Clarke School Carpentry Dept.
Not Applicable ❑
Company Name:
John Scott
Responsible In Charge of Construction
11 hunt Rd. Hawley, ma.
Address
,v (413) 339 -5508
Signal Telephone
Versionl.7 Commercial Building Permit May 15, 2000
S. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Q , Date Issued:
C. Do any signs exist on the property? YES NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO Q
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Version1.7 Commercial Building Permit May 15, 2000
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations El Existing Wall Signs ❑ Demolition El Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing 0 Change of Use ❑ Other ❑
Brief Description Moving ladies room egress door to new common hallway area, and blocking up old egress door
Of Proposed Work: to accommodate for a H/C bathroom and shower area
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly A -1 ❑ A -2 ❑ A -3 ❑ 1A I ❑
A -4 ❑ A -5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C I ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1 -1 ❑ 1 -2 El 1 -3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑
S Storage ❑ S -1 ❑ S -2 ❑ 5B [ ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor (sf)
1st 110 1st 110
2nd 2nd
3 rd
3rd
4 th
4
Total Area (sf) 110 Total Proposed New Construction (sf)
1 1 0 ,
Total Height (ft) 8
Total Height ft 8
7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public p Private ❑ Zone Outside Flood Zone p Municipal p On site disposal system 0
Versionl.7 Commercial Building Permit May 15, 2000
Department us nly
City of Northampton Status of Perm
Building Department Curb Cut/Drivew rn 212 Main Street sewer /Septt v
Room 100 Water/V11 A ity
Northampton, MA 01060 Two Seth „of Structural Plafs
phone 413- 587 -1240 Fax 413- 587 -1272 Pl ot/Site F�I AV
-r' r
Other Specify t v? " C
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANc t , OR DEMOtiSH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
52 Roundhill Rd.. Map Lot Unit
Clarke School Gymnasium
Zone Overlay District
Northampton, Ma. 01060
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Clarke school f he deaf 46 Roundhill Rd. Northampton , Ma.
Name (Print) , Current Mailing Address:
(413) 582- 1111
Signature Telephone
2.2 Authorized Agent:
Steve Balicki bit/ p'' 46 Roundhill Rd. Northampton, Ma
Name (Print) Current Mailing Address:
(413) 582 -1111
Signature Telephone
SECTION 3 - ESTIMATE ONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building $12,500.00 (a) Building Permit Fee
2. Electrical $12,000.00' (b) Estimated Total Cost of
Construction from (6)
3. Plumbing $9,960.00 Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection $1,000.00
6. Total = (1 + 2 + 3 + 4 + 5) 55/7 (00 Check Number - ,o3
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
1
File # BP- 2010 -0097
APPLICANT /CONTACT PERSON JOHN SCOTT
ADDRESS /PHONE 11 HUNT RD HAWLEY (413) 339 -5508 0
PROPERTY LOCATION 52 ROUND HILL RD - CLARKE SCHOOL GYMNASIUM
MAP 31B PARCEL 004 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATIONCICKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out /-n
Fee Paid ( f73 -' a —
Tvpeof Construction: MOVE LADIES ROOM EGRESS DOOR FOR H/C BATH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 078899
3 sets of Plans / Plot Plan
THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN ATION PRESENTED:
Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
Signature of Building Offi ial Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
52 ROUND HILL RD - CLARKE SCHOOL GYMNASIUM ' . BP- 2010 -0097
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31B - 004 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP -2010 -0097
Project # JS- 2010- 000113
Est. Cost: $35460.00
Fee: $212.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN SCOTT 078899
Lot Size(sq. ft.): 311018.40 Owner: Clarke School for the Deaf
?. na: ' 'Rai % a n ; >. nt: JOHN SCOTT
AT: 52 ROUND HILL RD - CLARKE SCHOOL GYMNASIUM
Applicant Address: Phone: Insurance:
11 HUNT RD (413) 339 -5508 0
HAWLEYMA01339 ISSUED ON ::7/31/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:MOVE LADIES ROOM EGRESS DOOR FOR H/C
BATH
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground / et. , 'Service: Meter:
: _
Footings:
Rough: aC 2 C7 Rough: House # Foundation:
, Driveway Final:
/tt
Final: 0-,;20 9 ! Final: �.a q J
/ �
, / Rough Frame: - 4;1
`; 3�
Gas: Fire Department Fireplace /Chimney:
Rough: :: F_:.::: °_nt ott:
Final: Smoke: Final: do t 0 . 4 11,------
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATION '' 00 ,,
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 7/31/2009 0:00:00 $212.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo